Gains Made During Stroke Recovery Fade Over Time

Action Points

Explain to interested patients that the study revealed a trajectory of recovery then gradual loss of independence after a stroke.

Note that the study did not have a control group for comparison of functional decline over time not related to stroke.

SAN FRANCISCO, June 25 -- After the initial poststroke recovery period, patients slowly lose independence rather than remaining stable as expected, researchers said.

Beyond the first six months after an ischemic stroke, the likelihood of retaining ability to live with little assistance dropped as much as 9% per year over five years, Mandip S. Dhamoon, MD, MPH, of Columbia University in New York, and colleagues reported in Stroke: Journal of the American Heart Association.

Their population-based study revealed a particularly prominent decline in functional status among those with poorer health insurance coverage and thus poorer access to healthcare.

"Reasons for this decline may include poor management of comorbid diseases (such as diabetes and hypertension), 'silent' recurrent ischemic events, or depletion of 'functional reserve,' " Dr. Dhamoon said.

Traditionally, most stroke patients are expected to make a partial recovery in the first months to a year followed by little change in functional status such that stroke is seen as an episodic condition, he noted.

"Our data suggest that, in terms of function, stroke could be considered a chronic condition showing a steady decline over time, even in the absence of discrete 'events' such as recurrent strokes or heart attacks," Dr. Dhamoon said.

Most studies of the poststroke functional trajectory have included only hospitalized patients with limited follow-up.

So for a long-term look, Dr. Dhamoon's group analyzed findings from 525 patients 40 and older who were prospectively followed after an ischemic stroke in the Northern Manhattan Study.

The population-based cohort study was originally designed to determine predictors of stroke recurrence and prognosis in a multiethnic, urban area.

Assessment with the Barthel Index of functional status at six months and annually to five years revealed a progressive decline in the proportion of patients with good functional status.

The odds ratio of having a score of 95 or higher dropped 6% per year after stroke when controlling for demographic variables (adjusted OR 0.94, 95% confidence interval 0.89 to 1.00) without attenuation when further adjusting for medical risk factors.

The decline in the likelihood of good functional status became more pronounced after adjusting for stroke characteristics such as severity, neglect, side of stroke, and urinary incontinence (adjusted OR 0.91 per year after stroke, 95% CI 0.84 to 0.99).

Even those who had early functional recovery at six months showed a significant annual decline in likelihood of remaining independent during the rest of follow-up (fully adjusted OR 0.76 per year, 95% CI 0.65 to 0.89).

Although the trend appeared linear, the greatest functional declines began to occur at three years poststroke.

Factors associated with lower likelihood of remaining independent throughout five years included:

Medicaid or no insurance (adjusted OR 0.84, P=0.003) rather than Medicare or private insurance (adjusted OR 0.99, P=0.92)

Older age at the time of the stroke (adjusted OR 0.95, P<0.0001)

Diabetes (adjusted OR 0.48, P=0.0006)

Unmarried (adjusted OR 1.82 for married status, P=0.016)

Higher stroke severity (adjusted OR 0.06, P<0.0001)

Urinary incontinence within a week of the stroke (adjusted OR 3.80 for continence, P<0.0001)

The reason for the impact of insurance status might have been that patients with poorer access to healthcare were less likely to get ongoing rehabilitation and were less able to manage their blood pressure and other risk factors, Dr. Dhamoon suggested.

"Access to healthcare is not just important around the time of the stroke but in the years following, when those with poor access do worse in their functioning and ability to be independent," he said.

He cautioned, though, that while this magnitude of functional decline would not be expected from aging alone, the study could not rule this out.

In addition to lack of an age- and risk-factor matched control group, the study was limited by use of the Barthel Index rather than a disability scale designed specifically for stroke and lack of data on poststroke rehabilitation.

The authors also noted that "because some of the data on baseline risk factors was obtained by self-report, uninsured participants who do not regularly get medical care may not be aware of undiagnosed conditions."

The National Institutes of Neurological Disorders and Stroke funded the study.